A patient- and acquisition-tailored injection approach for improving consistency of CT enhancement towards a target CT value in coronary CT angiography

Background: Unoptimized coronary CT angiography (CTA) exams typically result in a highly variable arterial enhancement (HU a) across patients. This study aimed at harmonizing arterial enhancement by implementing a patient-, contrast- and kV-tailored injection protocol. Methods: First, the optimal body size metric to predict HU a was identified by retrospectively analysing images of 76 patients, acquired with 70 ml contrast media (G1). Second, using phantom experiments, correction factors for the effect of kV and contrast concentration on HU a were determined. Third, a model was developed, prescribing the optimal contrast dose to be injected to obtain a diagnostically appropriate arterial target enhancement HU target. The model was then validated on 278 prospectively collected patients, in two groups with two different HU target: 525 HU (207 patients, G2A) and 425 HU (71 patients, G2B). The HU a histograms were compared among groups and to the target enhancement through their mean and standard deviation (SD) at 100 kVp reference level. Also, signal-to-noise ratio was obtained and compared among the groups. Results: Fat free mass (FFM) showed the highest correlation with HU a (r = 0.69). KVp correction factors ranged from 0.65 at 70 kVp to 1.22 at 140 kVp. The obtained model reduced the group heterogeneity (SD) from 101HU for reference G1 to 75HU (p < 0.001) for G2A and 68HU (p < 0.001) for G2B. The mean HU a of 506HU in G2A was slightly below HU target = 525HU (p = 0.01) whereas in G2B, the mean HU a of 414HU was not significantly different from HU target = 425HU (p = 0.54). The total iodine dose was lowered from 19.5 g-I to 17.6 g-I and 14.2 g-I from G1 to G2A and G2B, on average. Conclusion: A contrast injection model, based on patient's fat free mass and accounting for the contrast agent concentration and the planned CT-scan tube voltage, harmonized arterial enhancement among patients towards a predefined target enhancement in coronary CTA scanning, without affecting the bolus timing.